Primary angiosarcoma of the aorta, great vessels, and the heart

Ruptured aortic aneurysm with previous endovascular aneurysm repair in a patient with high-grade angiosarcoma

Ruptured aortic aneurysms after endovascular repair is rare, particularly in the absence of type I or type III endoleaks. In such cases, a thorough investigation into the causes is imperative, including the consideration of an underlying malignancy. We report a case involving a 78-year-old woman who experienced abdominal aortic aneurysm rupture 4 years after aortic endograft treatment. We explanted the endograft and performed aortobi-iliac bypass. Initial aortic thrombus pathological analysis revealed atherosclerosis. However, the patient returned 4 months later with multiple lesions suggestive of metastases, and a reevaluation of the pathology slides uncovered a diagnosis of angiosarcoma.

Aortic Sarcoma Patients with Bone Metastasis

BACKGROUND

Metastases to the bone of aortic sarcoma include osteolytic and nonosteolytic lesions. This study aims to review the clinical symptoms, the sites, and diagnostic methods of bone metastases and to compare the osteolytic and nonosteolytic metastases of patients with aortic sarcoma.

METHODS

A systematic search was conducted in PubMed and scientific journals published from 1972 to 2022. Database included reports of aortic sarcomas with bone metastasis published in English and in French. Characteristics of patients were analyzed with chi-square test or Fisher's exact test between lytic and sclerotic bone metastases.

RESULTS

In 29 patients with bone destruction, the symptoms of low back pain and claudication were observed in 10 (34.5%) and 9 cases (31%), respectively. Acute ischemia of the legs and arms accounted for 7 cases (24.1%). There were 4 cases with hypertension (13.8%) and 5 cases with chest pain or abdominal pain or epigastric pain (17.2%). Metastases to the vertebrae, pelvis, and femur were observed in 14 (48.3%), 12 (41.4%), and 11 cases (37.9%), respectively. Osteolytic lesions were detected at the time of diagnosis in 16/29 (55.2%) cases. In 27 aortic sarcoma patients with sclerotic bone metastases, symptoms of hypertension were observed in 10 (37.0%), of back pain in 7 (25.9%), of chest pain or abdominal pain in 5 cases (18.5%). Acute ischemia of the leg occurred in 6 cases (22.2%). Metastases to the vertebrae, bone, pelvis, and femur were observed in 10 (37.0%), 9 (33.3%), 7 (25.9%), and 6 cases (22.2%), respectively. The sign of claudication and methods for detected bone destruction by X-rays were the difference between osteolytic and nonosteolytic metastases of aortic sarcoma (P = 0.019; P = 0.001), respectively.

CONCLUSIONS

Back pain is a common symptom of aortic sarcoma with bone metastasis. The sign of intermittent claudication is the difference between osteolytic and nonosteolytic metastases of aortic sarcoma. Bone destruction occurred in all bones, but mainly in vertebrae, pelvis, and femur. Methods for detection of bone destruction are mainly by X-rays or computed tomography (CT). Bone destruction was an important sign to detect aortic sarcoma. Sclerotic bone metastases occurred mainly in vertebrae, pelvis, bone, and femur. The detection of sclerotic bone metastases is based on magnetic resonance imaging, positron emission tomography/CT, and autopsy.

Development of an Undifferentiated Pleomorphic Sarcoma After Aortic Aneurysm Graft Replacement: A Case Report and Literature Review

Aortic sarcomas are extremely rare. Sarcomas associated with aortic graft replacement are even rarer; only 17 cases have been examined through immunohistochemical staining to date, most of which were either angiosarcomas or intimal sarcomas. Here, we report the case of an 88-year-old man with an undifferentiated pleomorphic sarcoma (UPS) that developed after aortic graft replacement and was diagnosed through postmortem autopsy. To the best of our knowledge, this is the first case of graft-associated sarcoma diagnosed as an undifferentiated pleomorphic type following detailed immunohistochemical staining with sufficient antibodies and fluorescencein situ hybridization (FISH).

A case of left atrial intimal sarcoma with rhabdomyosarcoma differentiation: a case report and literature review

Primary cardiac malignancies are rare, with cardiac sarcomas being the main type. Among these, intimal sarcomas are the most common. However, they tend to occur in the great vessels and are rare in the heart, with only a few isolated cases reported. We report a challenging case of a patient with left atrial intimal sarcoma with rhabdomyosarcoma differentiation. The patient was admitted after a physical examination detected left heart occupancy, and initial imaging suspected a left atrial thrombus. The patient then underwent extracorporeal circulation-assisted open cardiac surgery with resection of an atrial mass. The postoperative pathological findings were suggestive of an arterial intimal sarcoma, which included areas of rhabdomyosarcoma differentiation within the tumor tissue. Unfortunately, the patient's tumor recurred 4 months later, and she died due to treatment failure. This case highlights the rarity and risk of misdiagnosis of cardiac intimal sarcoma. Additionally, we aim to improve the understanding of intimal sarcoma through a review of immunohistochemistry and gene amplification techniques.

Etiology, pathogenesis, and management of angiosarcoma associated with implants and foreign body: Clinical cases and research updates

Angiosarcomas are rare and highly malignant soft tissue sarcomas originating from endothelial cells lining the lymphatic or vascular system. While they predominantly emerge from (sub)cutaneous regions, occurrences have been reported throughout the body. The etiology of angiosarcoma remains elusive in most clinical cases. Nevertheless, several prognosis risk factors play a pivotal role, including chronic lymphedema, therapeutic irradiation, environmental carcinogens, familial syndromes, and the presence of foreign materials like metallic objects and biomedical implants. Despite evidence implicating retained foreign material in angiosarcoma development, understanding its prognosis and pathogenesis remains limited. The pathogenesis of angiosarcoma appears to involve a complex interplay of chronic inflammation, tissue remodeling, and genetic factors that create a conducive microenvironment for malignant transformation. Management of these sarcomas remains challenging due to their infiltrative nature owing to the high chance of metastasis and local recurrence. The primary treatment modalities currently include surgery, radiotherapy, and chemotherapy, but recent advances in targeted immunotherapy and gene therapy hold promise for more effective approaches. This comprehensive review delves into the potential etiological and pathogenic roles of foreign materials, such as metallic objects, biomedical implants, and biomaterials, in the development of angiosarcoma. Further research into the underlying molecular mechanisms could provide valuable insights for tailored management and developing novel targeted therapeutic strategies.

Multimodality treatment of primary cardiac angiosarcoma: A systematic literature review

BACKGROUND

Primary cardiac angiosarcoma (PCA) is the most prevalent histological type of cardiac sarcoma but its rarity poses a challenge for standardizing treatment protocols. Moreover, published studies are limited by small patient numbers and lack of randomization, making it challenging to establish evidence-based treatment strategies. This systematic review aims to consolidate the heterogeneous published data and identify factors related to the treatment outcome of PCA patients.

METHODS

The PubMed and Scopus bibliographic databases were systematically searched for original articles reporting clinical, treatment and outcome data for PCA patients. Kaplan-Meier analysis was used to calculate the time to progression and survival. The Log-Rank test was used to compare progression-free and overall survival data. The Cox proportional hazards regression model was used for univariate and multivariate analysis of survival data.

RESULTS

A total of 127 studies containing data for 162 patients were analyzed. The median age of the patient cohort was 45 years, with males being 1.5 times more frequently affected than females. Tumors were primarily located on the right side of the heart, with a median size of 6 cm. Median progression-free and overall survival of 5 months and 12 months, respectively, were calculated. Age, sex, and resection margins did not have a significant impact on PCA survival, as determined by both univariate and multivariate analyses. The presence of metastases at diagnosis was associated with lower overall survival in univariate analysis, although this effect was not significant in multivariate analysis. Multimodality treatment that incorporated surgery and adjuvant chemo-radiotherapy was associated with a statistically significant survival benefit. Median overall survival increased from 6 months with surgery alone to 13 months and 27 months with adjuvant chemotherapy and chemo-radiotherapy, respectively.

CONCLUSION

Multimodality treatment including surgery and chemo-radiotherapy was found to offer the greatest survival benefit for PCA patients.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Do Not Forget the Oncovascular: Acute Limb Ischaemia Due to Aortic Epithelioid Angiosarcoma

Introduction

Aortic epithelioid angiosarcoma (AEA) is a rare malignant tumour and can cause acute limb ischaemia.

Report

A 66 year old man was admitted with acute pulmonary oedema due to bilateral renal artery stenosis. An incidental osteolytic left sacral lesion was found on computed tomography angiography, and extensive work up revealed an AEA. Follow up was marked by acute left lower limb ischaemia 13 months later and right chronic limb threatening ischaemia 15 months later.

Discussion

Physicians need to consider AEA as an aetiology for acute or chronic limb ischaemia in patients with altered general status but mostly with intra-aortic irregular vegetations without any calcification and parietal involvement on computed tomography angiography.

Role of radiotherapy in the management of rare solid thoracic tumors of the adults

Thoracic tumors include more than one hundred histopathological subtypes. Rare thoracic malignancies can be defined as representing less than 1% of all thoracic tumors. The European Rare Cancer Surveillance Project (RARECARE) identified rarity as an incidence less than 6 for 100,000 people, with significant difference of prevalence between them. Modalities of treatment for these pathologies include surgery, radiotherapy, and systemic therapies. In this article, we aim to discuss role and techniques of radiotherapy in management of rare solid thoracic tumors in adults, focusing on different anatomical locations such as lung parenchyma, mediastinum, vessels, chest wall and pleural cavity.

Vascular Malformations and Tumors: A Review of Classification and Imaging Features for Cardiothoracic Radiologists

The International Society for the Study of Vascular Anomalies (ISSVA) classification is a comprehensive histology-based scheme that was updated in 2018. It is important for cardiothoracic imagers to understand this classification to ensure that accurate terminology is used and that archaic terms are avoided when vascular lesions are described. Knowledge of the various malformations (including common conditions, such as venous malformation, arteriovenous fistula, and arteriovenous malformation) and vascular tumors allows for timely diagnosis and appropriate management. This review describes various vascular anomalies, in accordance with ISSVA classification and terminology; highlights key imaging features associated with each; and discusses the role of different imaging modalities. Keywords: Pulmonary, Soft Tissues/Skin, Vascular, Arteriovenous Malformation © RSNA, 2023.

A case report of pulmonary artery intimal sarcoma negative for 18F-FDG mimicking pulmonary thromboembolism

Background

Pulmonary artery sarcoma is a rare malignant neoplasm arising from intimal mesenchymal cells in the pulmonary artery wall and is often difficult to differentiate from pulmonary embolism, however, 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can be useful for a differential diagnosis. Here, we present a rare case of pulmonary sarcoma undetectable by PET.

Case summary

A 77-year-old woman who had worsening dyspnoea on effort for a month and progressive chest discomfort with nocturnal cough for a week presented to our hospital. Contrast-enhanced computed tomography (CT) demonstrated a massive filling defect in the left pulmonary artery (PA). Two major differential diagnoses were considered; pulmonary thromboembolism and tumour-like lesions. Positron emission tomography-computed tomography (PET-CT) revealed that there was no abnormal accumulation of 18F-FDG in the mass. However, even after effective anti-thrombotic treatment for 3 weeks, a follow-up CT showed no reduction at all in the size of the lesion in the pulmonary artery. Therefore, surgery for diagnostic therapeutic purposes was performed.

Discussion

The present case is informative because it supports the idea that being aware of PA angiosarcoma as a potential differential diagnosis of pulmonary thromboembolism is essential, particularly in cases of no evident peripheral venous thrombosis and a negative D-dimer test, even if neither heterogenous contrast enhancement in CT and magnetic resonance imaging nor accumulation of 18-FDG in PET-CT is evident.

Complex Vascular Resections for Retroperitoneal Soft Tissue Sarcoma

Retroperitoneal sarcomas (RPSs) are locally aggressive tumors that can compromise major vessels of the retroperitoneum including the inferior vena cava, aorta, or main tributary vessels. Vascular involvement can be secondary to the tumor's infiltrating growth pattern or primary vascular origin. Surgery is still the mainstay for curing this disease, and resection of RPSs may include major vascular resections to secure adequate oncologic results. Our improved knowledge in the tumor biology of RPSs, in conjunction with the growing surgical expertise in both sarcoma and vascular surgical techniques, has allowed for major vascular reconstructions within multi-visceral resections for RPSs with good perioperative results. This complex surgical approach may include the combined work of various surgical subspecialties.

Primary undifferentiated high-grade pleomorphic cardiac sarcoma in the left atrium with atypical presentation

A woman in her 60s had 4 months of malaise, fatigue, dyspnoea, night sweats and grade 3 clubbing. She had a pansystolic murmur and signs of congestive heart failure. Multimodal imaging with a transthoracic echocardiogram, transoesophageal echocardiogram and CT was carried out to diagnose and reconstruct the mass for surgical planning. A 2×2.8 cm circular dense mass was found in the left atrium with vegetations on the mitral valve. Positron emission tomography and cardiac MRI confirmed the mass's hypermetabolic activity and malignant features. Mitral valve replacement and surgical resection were performed. She was diagnosed with grade 3 undifferentiated cardiac sarcoma and referred to the sarcoma multidisciplinary team for further management given sarcoma's rarity and complexity. The poor prognosis of sarcoma was evident as her symptoms recurred 2 months postoperatively.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Genetic insights into cardiac tumors: a comprehensive review

Cardiac neoplasms are rare, however, also a curable form of the disease once detected early. In recent years the viscus tumors have gained their highlights, due to the advancement in techniques like echocardiography both 2D and 3D, MRI, etc. These cardiac tumors are divided based on their benign and malignant nature and also as well as primary and secondary cardiac tumors. Largely the primary cardiac tumors are often than secondary cardiac tumors. The secondary tumor happens anywhere in the body involving the heart. The most common malignant tumors are sarcoma, some are angiosarcomas, fibromas, rhabdosarcoma, and leiomyosarcoma. The primary sarcoma affects both men and women at an equal rate with non-specific symptoms. These conditions led to high demand in genomic testing that helps in spot the mutation that leads to the particular type of cardiac neoplasm and it additionally helps to screen the mutated sequence and stop it from being inherited. Recent studies on cardiac tumors have revealed many genes that are involved in tumorigenesis and technologies have enabled the right screening of the tumor location within the heart and their histopathological studies were also studied. This review principally focuses on the understanding of the various forms of cardiac tumors, genetic variants involved and their influence, genetic testing, and different diagnostic approaches in cardiac tumors.

Angiosarcoma and Vascular Surgery A Case Report and Review of the Literature to Focus on a Possible Risk Factor

INTRODUCTION

Angiosarcomas (AS) are rare and aggressive neoplasms originating from the endothelium: they represent less than 2% of all soft tissue sarcomas and usually have a poor prognosis. Although more often primary, different risk factors have been described and some cases are associated with vascular surgery. Materials and Methods: We present the case of an 84-year-old man who developed an AS on his thigh 3 years after a popliteal bypass with autologous saphenous vein. We performed a thorough review of the literature describing the main characteristics of the 25 cases (including ours) of AS associated with vascular surgery reported from 1981 to 2022. Results: Most of the patients were males (21 men vs 4 women) with a range age of 50-84 years. Most of AS are associated with Dacron grafts (12 cases), the overall mean time to onset is 7.8 years after surgery. The most common presenting symptoms are pain (20 cases) and weight loss (10 cases), while cutaneous presentation is uncommon; indeed, violaceous and painful papules, plaques, nodules, and skin ulceration have been found in 3 cases only. Due to unspecific symptoms, differential diagnosis is often difficult and a biopsy for histological confirmation is mandatory. Conclusion: Even if it seems to be a very rare complication, AS should always be considered in patients with compatible symptoms and who have undergone vascular surgery in the past.

Outcomes of Interventions for Angiosarcoma

Objective

Angiosarcoma is a rare malignant vascular tumor, and the management and outcome of this disease are not well-described. The aim of this study was to report the incidence, patient demographics, and outcomes of angiosarcoma based on national data.

Methods

Data on patients with angiosarcoma were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. Inverse probability treatment weights (IPTW) were used to assess the survival benefit of operation with additional chemo or radiation therapy compared to operation alone. These variables were further compared against patients who did not receive an operation despite being initially offered one. Cox regression was used to assess survival. Statistical analyses were performed on RStudio.

Results

For this study, 5,135 patients (46% men; median age 69, range 0–102) with angiosarcoma were identified in the SEER database between 1975 and 2016. The age-adjusted incidence rate was 1–4%. Patients were mostly non-Hispanic Caucasian (75.4%). The average tumor size was 4.7 cm, range (.1–98.9). Tumor grades were high at presentation (Grade III 17.2, Grade IV 19, and unknown 50.6%), but half were considered localized tumors. Most patients underwent an operation (66.1%). In 5.6% of patients, the operation was recommended but not performed. The overall 5-year survival was 26.7% (95% CI 25.4–28.1%). IPTW with adjusted Cox proportional hazard model demonstrated worse survival, showing that operation compared to no operation and operation with chemo/radiation compared to operation alone had worse survival between months 0 and 25 but had improved survival after month 25.

Conclusions

The incidence of angiosarcoma is low and long-term survival is poor. Multimodal therapy in the form of neoadjuvant or adjuvant chemo/radiation therapy offers significant long-term survival benefits over operation alone.

Complete resection and arterial reconstruction for primary sarcoma arising from superior mesenteric artery

In the treatment of retroperitoneal sarcoma involving major vessels, complete resection with vascular reconstruction is challenging. We describe the case of a 72-year-old man who presented with 8 months of abdominal pain. Diagnostic workup revealed occlusion of the celiac trunk and the origin of the superior mesenteric artery due to a soft tissue sarcoma. Radical resection of the tumor and vessels was performed. Guided by intraoperative angiography, arterial reconstruction was performed without mesenteric ischemia. All arterial margins were negative. At the 6-year follow-up, the patient was alive with no evidence of recurrence.

Angiosarcoma after endovascular aneurysm repair: case report and literature review

INTRODUCTION

Epithelioid angiosarcoma is a rare soft tissue sarcoma with a poor prognosis. We report two cases of patients who presented with a history of lower back pain, inflammatory signs and weight loss 5 and 6 years after endovascular aortic repair (EVAR) of an elective infrarenal abdominal aortic aneurysm (AAA). Imaging suggested graft infection but tissue samples revealed an epithelioid angiosarcoma. The objective is to report the clinical presentation, investigative modalities and immunohistochemical findings of an angiosarcoma after EVAR.

PATIENTS AND METHODS

Two cases are described of an angiosarcoma of the aorta after EVAR. A literature search using PubMed, Embase and Web of Science was performed in English about angiosarcoma after EVAR published between 2007 and 2021. Relevant reports were selected and analysed.

RESULTS

Fifteen case reports were identified, including the current two cases. Time to tumour detection after EVAR ranged from 6 to 120 months with a mean interval of 68 months. Most patients underwent endovascular repair of an AAA (13/15). Males (13 male/2 female patients) were predominant with a median age of 72 years (IQR 68-78 years). Over half of the patients had metastases at the time of diagnosis (9/15), most frequently in bones and liver.

CONCLUSION

Diagnosis of angiosarcoma after EVAR remains challenging due to indistinctive clinical and radiological findings mimicking graft infection or endoleak. Angiosarcoma should be included in the differential diagnosis in patients previously treated with EVAR presenting with unintended weight loss, abdominal back pain and contrast enhancement of the aortic wall.AbbreviationsAAAabdominal aortic aneurysmCTAcomputed tomography angiographyCRPc-reactive proteinEVARendovascular aortic repairESRerythrocyte sedimentation rateFDGfluoro-deoxyglucoseMRImagnetic resonance imagingMeSHmedical subject headings.

Recurrent malignant peripheral nerve sheath tumor presenting as an asymptomatic intravenous thrombus extending to the heart: a case report

Background

Malignant peripheral nerve sheath tumor (MPNST) is a rare soft tissue sarcoma mainly treated via surgical resection. Herein, we report a case of MPNST wherein a massive tumor thrombus extended to the major veins and heart.

Case presentation

A 39-year-old female with a history of neurofibromatosis type 1 developed MPNST from the right radial nerve. In addition to adjuvant chemotherapy, she underwent wide tumor resection and concomitant radial nerve resection, followed by postoperative radiotherapy. Histological evaluation revealed marked venous invasion. The 2-year follow-up CT revealed an asymptomatic recurrent tumor thrombus extending from the right subclavian vein to the heart. An urgent life-saving operation was performed to ligate the base of the right subclavian vein and remove the entire intravenous thrombus that extended to the right ventricle. The remaining tumor in the right subclavian vein increased in size 3 months after thrombectomy. After confirming the absence of any metastatic lesions, the patient underwent extended forequarter amputation to achieve surgical remission. One year later, a new metastasis to the right diaphragm was safely resected. The patient remains alive without any evidence of disease 2 years after the extended forequarter amputation.

Conclusions

In cases of a previous history of microscopic venous invasion, recurrence can occur as a massive tumor thrombus that extends to the great vessels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02473-2.

Mediastinal tumours and pseudo-tumours: a comprehensive review with emphasis on multidisciplinary approach

The diagnosis of a mediastinal mass may be challenging for clinicians, since lesions arising within the mediastinum include a variety of disease entities, frequently requiring a multidisciplinary approach. Age and sex represent important information, which need to be integrated with imaging and laboratory findings. In addition, the location of the mediastinal lesion is fundamental; indeed, we propose to illustrate mediastinal diseases based on the compartment of origin. We consider that this structured approach may serve as hint to the diagnostic modalities and management of mediastinal diseases. In this review, we present primary mediastinal tumours in the evolving context of new diagnostic and therapeutic tools, with recently described entities, based on our own experience with >900 cases encountered in the past 10 years.

Given the mediastinal anatomical heterogeneity, the correct positioning of mediastinal lesions becomes primal, in order to first establish a clinical suspicion and then to assist in planning biopsy and surgical procedurehttps://bit.ly/3p0gsk3

Primary Aortic Angiosarcoma: A Review of Two Cases Highlighting Unique Imaging and Clinical Characteristics

Angiosarcomas are rare vascular connective tissue tumors originating from the tunica intima, media, or adventitia and may arise in large vessels. Here two cases of primary angiosarcoma of the aorta are described that highlight initial manifestations and unique complications from diffuse arterial tumor emboli, which led to delayed cancer diagnosis. In patients with aortic lesions, imaging characteristics must be thoughtfully reconciled with clinical scenarios, particularly in patients with no additional evidence of atherosclerosis or vasculitis. Keywords: Oncology, Neoplasms-Primary, MR-Angiography, Aorta © RSNA, 2021.

Primary angiosarcoma of aorta: A systematic review

PURPOSE

To elucidate the epidemiology, anatomical, presentation, classification, pathology, investigative modalities, management and prognosis of primary angiosarcoma of the aorta.

MATERIAL AND METHODS

A systematic review of literature from the database inception to January 2021 in PubMed and Embase, CINAHL and Cochrane Library in accordance to PRISMA was conducted. Retrieval and extraction was performed by two independent reviewers. The hierarchy of the evidence was assessed through the National Institute for Health and Care Excellence Checklist. Data were subjected to pooled prevalence analysis, Kaplan-Meier survival and test of probability using log-rank analysis. This review is registered with International Prospective Register of Systematic Reviews: RD42021231314.

RESULTS

82 studies with n = 123 cases met the inclusion criterion. Abdominal (45%) aorta was the commonest anatomical site with female predominance in ascending aorta (4:1) and aortic arch (2:1). The longest survival was in the ascending aorta and the shortest in the abdominal aorta [540 (interquartile range [IQR], 7-1560 days vs. 180 (IQR, 1-5730 days)], respectively. The overall median survival was 210 days (IQR, 1-5730 days) or 7 months. Lack of metastasis (47%) was a marker of longer survival (p < 0.03) irrespective of other attributes.

CONCLUSION

The pathophysiology appears to be a trend of increasing fatigue, fever and weight loss associated with segmental dysfunction of the aorta projecting occlusive or destructive phenotypes. Computed tomography angiography features of volume-occupying, bulky, polypoid (intraluminal), protrusive vegetation, hyper vascular without atherosclerotic lesions are extremely suggestive of PA of the aorta at 5th and 6th decades of life.

Primary Soft Tissue Sarcoma of the Heart: An Emerging Chapter in Cardio-Oncology

Primary malignant cardiac tumors are rare, with a prevalence of about 0.01% among all cancer histotypes. At least 60% of them are primary soft tissue sarcomas of the heart (pSTS-h) that represent almost 1% of all STSs. The cardiac site of origin is the best way to classify pSTS-h as it is directly linked to the surgical approach for cancer removal. Indeed, histological differentiation should integrate the classification to provide insights into prognosis and survival expectancy of the patients. The prognosis of pSTS-h is severe and mostly influenced by the primary localization of the tumor, the difficulty in achieving complete surgical and pharmacological eradication, and the aggressive biological features of malignant cells. This review aims to provide a detailed literature overview of the most relevant issues on primary soft tissue sarcoma of the heart and highlight potential diagnostic and therapeutic future perspectives.

Aortic Angiosarcoma in Association with Endovascular Aneurysm Repair: Case Report and Review of the Literature

BACKGROUND Primary aortic sarcoma often poses diagnostic challenges for pathologists and clinicians because of a very low incidence and controversy over nomenclature and definition. We report a case of aortic angiosarcoma in association with a graft. We also conducted a clinicopathological review of cases of primary aortic sarcomas associated with implanted grafts. CASE REPORT The patient was an 82-year-old woman. She underwent thoracic endovascular aneurysm repair (TEVAR) at age 78 because of an aneurysm in the descending aorta. Approximately 4 years after the TEVAR, computed tomography revealed a type II endoleak and expansion of the aneurysm. Her c-reactive protein level rose to 34 mg/dL, and Ga scintigraphy showed 67Ga accumulation at the aneurysm. She had fever up to 39°C, and a stent graft infection was suspected. Despite administration of antibiotics, her condition deteriorated, and she died. Postmortem examination identified epithelioid aortic angiosarcoma at the aorta with aneurysm repair and the graft, and the aortic angiosarcoma invaded the left lower lobe of the lung. CONCLUSIONS Our clinicopathological review revealed that the proper clinical diagnosis was very difficult owing to confusion of aortic sarcoma after the implantation with the infected graft, atypical endoleak, or pseudoaneurysm. The histological diagnosis was ambiguous because immunohistochemical and genetic studies were not adequately conducted. Overall prognosis of aortic sarcoma is poor as most patients die within a year, with no effective treatments. It is hoped that recent projects for genomic medicine will provide useful insights about the diagnosis and treatment of these cancers.

Angiosarcoma of the Abdominal Aorta After Endovascular Aneurysm Repair: 18F-FDG PET/CT Imaging Findings

ABSTRACT

Primary angiosarcomas of the aorta are rare, highly aggressive malignant tumors for which there have been limited documented cases in the medical literature. Diagnosis is challenging due to nonspecific symptomatology and imitation of common aortic pathologies. A subset of these primary aortic angiosarcoma cases is seen in association with endovascular aneurysm repair, or EVAR; however, the connection between the 2 entities is not completely understood. Here, we present 18F-FDG PET/CT imaging findings of an angiosarcoma of the aorta in a 69-year-old man status post EVAR.

Major vascular resection in retroperitoneal sarcoma surgery

Major blood vessels may be invaded either by primary sarcomas arising from the vessel wall or by secondary infiltration of a retroperitoneal sarcoma. The involvement of major blood vessels is not considered to be an absolute contraindication for surgical resection. The main issue when evaluating a possible major vascular resection is to balance the possible surgical morbidity with the expected survival benefit. This is strictly related to the tumor's biology and clinical behavior and to the patient's performance status and comorbidities. A multidisciplinary approach in a specialized center is mandatory when approaching a possible oncovascular resection for retroperitoneal sarcoma, given the rarity and the heterogeneity of these tumors.

Infiltrating Angiosarcoma of the Ascending, Arch and Descending Aorta Manifested as Acute Mesenteric Ischemia

Primary malignant aortic tumors are rare and aggressive. Most cases are diagnosed at advanced stages or during autopsies with a median overall survival of 8 months from diagnosis. We present the case of a 59-year-old male with angiosarcoma involving all segments of the thoracic aorta and a large floating thrombus causing acute mesenteric ischemia, which was treated successfully with embolectomy. Graft replacement of the aorta should be considered in cases of localized disease and when patients are fit for surgery. The best medical and surgical treatment remains unclear, and further studies are needed.

Sarcoma of the Heart Treated with Stereotactic MR-Guided Online Adaptive Radiation Therapy

We present the first case in the literature of a patient with a histology-proven intimal sarcoma of the heart, recurrent after surgery, treated with stereotactic MR-guided online adaptive radiation therapy on an MR-Linac machine. The treatment was feasible and well tolerated. The CT scan 6 months after the last treatment showed stable disease.

Intimal Sarcoma of the Great Vessels

Intimal sarcomas of the pulmonary artery and aorta are rare entities with a poor prognosis. In many instances, pulmonary artery sarcomas are misinterpreted as acute or chronic pulmonary thromboembolism, whereas aortic intimal sarcomas are often misdiagnosed as protuberant atherosclerotic disease or intimal thrombus. Discernment of intimal sarcomas from these and other common benign entities is essential for the timely initiation of aggressive therapy. The most useful imaging modalities for assessment of a suspected intimal sarcoma include CT angiography, fluorine 18-fluorodeoxyglucose PET, and MRI. The authors discuss the clinical features, current treatment options, characteristic imaging findings, and underlying pathologic features of intimal sarcomas. The authors emphasize imaging discernment of intimal sarcomas and how their differential diagnosis is informed by knowledge of radiologic-pathologic correlation. The most reliable distinguishing imaging features are also emphasized to improve accurate and timely diagnosis. Online supplemental material is available for this article. ^©RSNA, 2021.

Chest CT Angiography for Acute Aortic Pathologic Conditions: Pearls and Pitfalls

Chest CT angiography (CTA) is essential in the diagnosis of acute aortic syndromes. Chest CTA quality can be optimized with attention to technical parameters pertaining to noncontrast imaging, timing of contrast-enhanced imaging, contrast material volume, kilovolt potential, tube-current modulation, and decisions regarding electrocardiographic-gating and ultra-fast imaging, which may affect the accurate diagnosis of acute aortic syndromes. An understanding of methods to apply to address suboptimal image quality is useful, as the accurate identification of acute aortic syndromes is essential for appropriate patient management. Acute aortic syndromes have high morbidity and mortality, particularly when involving the ascending aorta, and include classic aortic dissection, penetrating atherosclerotic ulcer, and acute intramural hematoma. An understanding of the pathogenesis and distinguishing imaging features of acute aortic syndromes and aortic rupture and some less common manifestations is helpful when interpreting imaging examinations. Related entities, such as ulcerated plaque, ulcerlike projections, and intramural blood pools, and mimics, such as vasculitis and aortic thrombus, are important to recognize; knowledge of these is important to avoid interpretive pitfalls. In addition, an awareness of postsurgical aortic changes can be useful when interpreting CTA examinations when patient history is incomplete. The authors review technical considerations when performing CTA, discuss acute aortic syndromes, and highlight diagnostic challenges encountered when interpreting aortic CTA examinations. ^©RSNA, 2021.

Pulmonary artery sarcoma masquerading as a pulmonary embolism

A 52-year-old woman was referred to the respiratory team with worsening shortness of breath for the last 3 months, which had deteriorated significantly over the last 2-3 weeks. She underwent a CT pulmonary angiogram, which was reported locally as showing a large pulmonary embolism. Given the chronic history and appearance of the thrombus, the patient was referred to a specialist pulmonary vascular disease multidisciplinary team and underwent a PET-CT scan with the diagnosis being felt to be more consistent with a pulmonary artery sarcoma. Within 4 weeks, she underwent a pulmonary endarterectomy which confirmed the presence of an extensive mass. She underwent bilateral endarterectomy and pulmonary artery valve replacement, with subsequent improvement of her breathlessness back to premorbid baseline. Postoperative histology has confirmed a pulmonary artery angiosarcoma. Alternate imaging modalities and early referral to a specialist unit allowed as early a diagnosis as possible with good symptomatic benefit.

An Unusual Case of Iron-Deficiency Anemia: The Culprit Hides in the Aorta

In a 72-year-old patient with anemia (Hb 7 g/dl), duodenoscopy exhibited an area of polypous irregular-looking mucosa. Histology revealed duodenal infiltration by epithelioid tumor cells, immunhistochemically positive for endothelial cell markers (CD34, CD31, ERG). Ultrasonography showed thrombotic material in the otherwise unremarkable abdominal aorta with some uptake of contrast bubbles on CEUS. Histological and clinical diagnosis assumed an epithelioid angiosarcoma of the thoraco-abdominal aorta at the level of the visceral and renal arteries with duodenal metastases.To prevent further shedding of tumor cells and aortic rupture, a branched stent-graft was placed into the thoraco-abdominal aorta. Palliative chemotherapy with gemcitabine and docetaxel was started, leading to a partial remission after 6 cycles. Three months later, however, there was a progress of the duodenal masses with new pulmonal and osseous metastases. Thirteen months after the initial diagnosis, death occured due to a hemorrhagic shock caused by a hematothorax.Aortic tumors are exceedingly rare, with only slightly more than 220 cases reported so far. In most cases, diagnosis is made either at autopsy or after an emergency operation for embolic complications like embolic intestinal ischemia. With an overall median survival of 8 months, prognosis is very poor.This case sensitizes for the correct sonographic interpretation of aortic "thrombi" in an otherwise normally appearing aorta, possibly with the aid of CEUS. Besides, it demonstrates the relatively early and uncommon diagnosis of an aortic angiosarcoma by the combination of endoscopy, immunohistochemistry, and ultrasonography.

Bleeding "sarcomatosis" as a rare presentation of vascular graft-related angiosarcoma: case report and review of the literature

Background

Angiosarcoma is a rare malignant tumor, originating from vascular endothelial cells, accounting for approximatively 1–2% of soft tissue sarcomas. It is characterized by a rapid proliferation and high metastatic potential. Some cases of angiosarcoma are described in association with vascular prosthesis, orthopedic devices and foreign bodies. Hereby, we report a case of a patient treated with the endovascular placement of a PTFE aorto bis-iliac prosthesis for aortic aneurysm, who developed a graft-related angiosarcoma with bone and peritoneal localizations. The peritoneal “sarcomatosis” led to an acute presentation with hemoperitoneum and anemia. We perform a thorough review of the literature summarizing the description of similar cases, their epidemiology and the possibilities for treatment.

Case presentation

An 84-year-old male with a history of abdominal aortic aneurysm endovascular repair presented to our emergency department complaining with low back pain radiating to the left limb. He underwent a type II endoleak embolization of the aneurysmal sac nine days before. During hospitalization he underwent a spine MRI which documented a vertebral alteration of non-univocal interpretation. Vertebral biopsy was performed revealing groups of cells of uncertain nature. He lately underwent percutaneous L2–L4 arthrodesis. Forty-two days after admission, he developed acute anemia. Emergency laparotomy revealed a massive hemoperitoneum and actively bleeding peritoneal nodules. Abdominal packing was performed, and several nodules were sent for definitive histological examination. After surgery, he developed progressive and severe hypovolemic shock and expired on postoperative day 5.

Conclusions

Angiosarcoma associated with foreign bodies, especially vascular prosthesis, is a very rare entity. In patients who have a history of prosthetic vascular graft placement that present with lumbar pain, osteolytic changes at radiologic imaging or the development of ascites, angiosarcoma should be considered in the differential diagnosis. Despite the poor prognosis, a prompt diagnosis might give access to an adequate treatment planning, with the aim for disease control and increased survival.

Vascular tumors of the mediastinum

Vascular tumors represent only a sliver of all tumors affecting the mediastinum, but they pose diagnostic challenges due to significant overlap among entities, ever-evolving classification schemes, and the exquisite rarity of some of the entities not only in the mediastinum but in pathology practice as a whole. Most of the vascular tumors are better known to the practice of soft tissue pathology, from which some of the knowledge of clinical behavior can be extrapolated. For example, the stratification of epithelioid hemangioendothelioma (EHE) into two biologically separate categories has effectively translated from the somatic soft tissues to the thorax. For other entities, the effective validation of soft tissue parameters is hindered by the small numbers of reported mediastinal cases. Many of the treatment modalities have also transferred over, with the key differences resting on the difficulty in achieving complete surgical resection for mediastinal tumors as opposed to those in the somatic soft tissues. Accordingly, systemic drug therapies have emerged as attractive options for some of the mediastinal vascular tumors, such as kaposiform hemangioendothelioma (KHE) and Kaposi sarcoma (KS). The categories presented herein mirror the classification scheme set forth by the 5th Edition WHO Classification of Soft Tissue and Bone Tumors. This review focuses on the biologically aggressive vascular neoplasms while limiting discussion of the benign entities to relevant comparisons in the differential diagnoses. While distinguishing among the benign entities has academic importance, in practice, the stakes are far higher for diagnosing the biologically aggressive tumors given their marked heterogeneity in clinical outcomes. Practical advice for problem areas in pathology will be reviewed alongside tumor pathobiology, including the latest in molecular diagnostics.

Diagnostic Enigma: Spindle Cell Sarcoma of the Aorta Presenting as Pulmonary Embolism and Chronic Anaemia

Primary aortic sarcoma is a rare and aggressive malignancy with only approximately 190 cases reported in the literature. While angiosarcoma and intimal sarcomas represent an estimated 67.7% of malignant aortic tumours, spindle cell sarcomas are even more exclusive, consisting of only 0.9% of malignant aortic tumours. Differentiated from other malignant aortic tumours, spindle cell sarcomas are of mesenchymal origin and usually express vimentin and osteopontin. Clinical presentations are variable and nonspecific, ranging from back pain, abdominal pain or elevated blood pressure, misleading to differentials like pulmonary emboli or aortic aneurysms such as in our case here. In this article, we discuss the finding of an extremely rare aortic sarcoma masquerading as a pulmonary embolism. The patient underwent surgical resection; however, the course was complicated by the development of brain metastases and intracranial haemorrhage. The literature is expanding regarding the evolution of adjuvant chemotherapy and radiation therapy in the treatment of these patients. The exact pathogenesis of spindle cell sarcomas is unknown but thought to be related to the MDM2-p53 pathway. The development of spindle cell sarcomas may be related to Li-Fraumeni syndrome, which should be on the differential for these patients. This case highlights the importance of identifying aortic sarcomas in patients who present with signs and symptoms of peripheral embolization as the diagnosis can be easily misconstrued for thrombus or aortic aneurysm, leading to a delay in proper and timely management. We herein emphasize that aortic sarcomas should be included in the clinician’s working differential due to the poor prognosis and outcomes that these aggressive tumours carry.

Manifestation of Pleomorphic Undifferentiated Aortic Sarcoma with Splenic Infarction: A Case Report

Aortic spindle cell sarcoma is a rare neoplasm with poor prognosis that is often found incidentally due to its adverse effects. CT and MRI with contrast are useful imaging modalities, but a tissue biopsy is the gold standard for diagnosis. Tumor resection is the ultimate treatment followed by chemotherapy. Our case was an adult female who presented mainly for shortness of breath, and further imaging workup demonstrated a soft tumor juxtaposed to a major vein with compressive effect. The patient's tumor was resected, and the pathology result confirmed undifferentiated aortic sarcoma. The patient's condition improved and she was discharged with outpatient oncology follow-up and possible treatment.

Diagnostic Accuracy of Cardiac Computed Tomography and 18-F Fluorodeoxyglucose Positron Emission Tomography in Cardiac Masses

OBJECTIVES

This study sought to assess the diagnostic accuracy of cardiac computed tomography (CT) and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) with positron emission tomography/computed tomography (PET/CT) in defining the nature of cardiac masses.

BACKGROUND

The diagnostic accuracy of cardiac CT and ¹⁸F-FDG PET/CT in identifying the nature of cardiac masses has been analyzed to date only in small samples.

METHODS

Of 223 patients with echocardiographically diagnosed cardiac masses, a cohort of 60 cases who underwent cardiac CT and ¹⁸F-FDG PET/CT was selected. All masses had histological confirmation, except for a minority of thrombotic formations. For each mass, 8 morphological CT signs, standardized uptake value (SUV_max, SUV_mean), metabolic tumor volume, and total lesion glycolysis in ¹⁸F-FDG PET were used as diagnostic markers.

RESULTS

Irregular tumor margins, pericardial effusion, invasion, solid nature, mass diameter, CT contrast uptake, and pre-contrast characteristics were strongly associated with the malignant nature of masses. The coexistence of at least 5 CT signs perfectly identified malignant masses, whereas the detection of 3 or 4 CT signs did not accurately discriminate the masses' nature. The mean SUV_max, SUV_mean, metabolic tumor volume, and total lesion glycolysis values were significantly higher in malignant than in benign masses. The diagnostic accuracy of SUV, metabolic tumor volume, and total lesion glycolysis ¹⁸F-FDG PET/CT parameters was excellent in detecting malignant masses. Among patients with 3 or 4 pathological CT signs, the presence of at least 1 abnormal ¹⁸F-FDG PET/CT parameter significantly increased the identification of malignancies.

CONCLUSIONS

Cardiac CT is a powerful tool to diagnose cardiac masses as the number of abnormal signs was found to correlate with the lesions' nature. Similarly, ¹⁸F-FDG PET/CT accurately identified malignant masses and contributed with additional valuable information in diagnostic uncertainties after cardiac CT. These imaging tools should be performed in specific clinical settings such as involvement of great vessels or for disease-staging purposes.

Primary sarcoma of the heart: case report and literature review

Background

Primary cardiac tumors are extremely rare. Most primary cardiac tumors are benign and around one quarter is malign. Sarcomas are accounting for 95% of these malign tumors and they show different histologies. The prognosis is poor with a mean survival of 3 months to 1 year, even with complete radical resection. We report the cases of two patients with primary cardiac sarcoma treated with surgery and radiation and/or chemotherapy. In addition we retrospectively collected data of patients with primary cardiac sarcoma treated between 2005 and 2019 with minimum follow-up of 12 months. Clinical characteristics, treatment modalities and outcomes were collected and analyzed. Finally a literature review was done.

Case presentation

The first patient presented with cerebellar infarction. When she developed a recurrence analysis showed a suspicious myocardial lesion for which irradical surgery (R2) was performed. Histopathology showed an intimal sarcoma of the left atrium. Postoperative radiotherapy was applied without complications. Three months after treatment multiple metastases were diagnosed and she died 13 months after initial diagnosis. The second patient presented with pericardial effusion. A tumor was found located in the right atrium and radical surgery was performed. Histopathology showed an angiosarcoma, without signs of metastases. Adjuvant radiotherapy was added because of close margins and based on high risk of recurrence and metastases it was decided to add chemotherapy. One year after finishing treatment, evaluation showed local recurrence together with pulmonary metastases.

Conclusions

Surgery combined with postoperative radiotherapy is feasible in patients with resectable cardiac sarcoma. Distant metastases occur frequently. In patients with an irresectable sarcoma of the heart primary radiotherapy should be considered.

Intravascular Epithelioid Angiosarcoma in the Abdominal Aorta Mimicking an Infected Aneurysm

Primary aortic angiosarcoma is very rare, and preoperative diagnosis is challenging with resultant poor prognosis. Angiosarcoma may mimic an infected aneurysm or a mural thrombus. Clinical suspicion of angiosarcoma is vital for an early diagnosis and proper surgical treatment, especially in cases with atypical rapid growth of an aortic abdominal aneurysm with a thrombotic mass. Herein, we report a case of angiosarcoma in the abdominal aorta mimicking an infected aneurysm and present computed tomography and positron emission tomography findings.

Predictors of survival in malignant aortic tumors

OBJECTIVE

Malignant aortic tumors (MATs) are exceedingly rare, and a comprehensive review of clinical and therapeutic aspects is lacking in the literature. The aim of this study was to analyze all known cases of MATs and to identify predictors of patients' survival.

METHODS

All patients diagnosed with an aortic tumor treated in a single center along with all case reports and reviews available in the literature through a specific PubMed search using keywords such as "malignant" and "aorta" or "aortic," "tumor," or "sarcoma" or "angiosarcoma" were analyzed. The tumor's primary location, clinical presentation, histologic subtype, and treatment choice were examined. Survival at 1 year, 3 years, and 5 years and the possible preoperative and operative outcome predictors were evaluated using Kaplan-Meier analysis with a log-rank test and by Cox regression for multivariate analysis.

RESULTS

In addition to the 5 cases treated in our center, 218 other cases of MAT were reported in the literature from 1873 to 2017. The mean age of the patients was 60.1 ± 11.9 years, and the male to female ratio was 1.59:1. The median overall survival from diagnosis was 8 (7-9) months; 1-, 3-, and 5-year survival rates were 26%, 7.6%, and 3.5%, respectively. Chronic hypertension (P = .03), fever (P = .03), back pain (P = .01), asthenia (P = .04), and signs of peripheral embolization (P = .007) were significant predictors of a poor result. Histologic subtypes had a different impact on survival, with no statistical significance. Compared with other treatment strategies, combined surgical-medical therapy had the best impact on the median survival rate (surgical-medical, 12 [8-24] months; medical, 8 [5-10] months; surgical 7 [2-16] months; no treatment, 2 [0.5-15] months; P = .001). Analyzing exclusively medical approaches, chemotherapy and radiotherapy had the best impact on median survival rate compared with untreated patients (chemotherapy-radiotherapy, 18 [10-26] months; radiotherapy, 16 [8-20] months; chemotherapy, 10 [7-24] months; no medical treatment, 6 [2-16] months; P = .005); these data were not sustained by multivariate analysis.

CONCLUSIONS

Aortic tumors are a malignant pathologic condition with a short survival rate after initial diagnosis. Survival is further diminished in the presence of clinical factors such as hypertension, fever, back pain, asthenia, and signs of peripheral embolization. Combined surgical and medical treatment, particularly with chemotherapy and radiotherapy, has shown the highest survival rate.

Aortic sarcoma mimicking a mycotic aneurysm in the thoracoabdominal aorta

Aortic sarcoma is a rare primary tumor with dismal prognosis. Here, we report a case involving a 74-year-old female patient with aortic sarcoma masquerading as a mycotic aneurysm in the thoracoabdominal aorta. She underwent aortic resection with Dacron prosthetic graft replacement because of rapid growth. The postoperative pathological findings of the resected specimen confirmed the diagnosis of aortic mural sarcoma, which was an unexpected result based on repeat computed tomography angiography performed within 2 months preoperatively. The preoperative diagnosis of aortic sarcoma is often difficult because of its rarity, and this case demonstrates some of the diagnostic pitfalls.

Angiosarcoma of the abdominal aorta after endovascular aneurysm repair

Primary aortic sarcoma is a rare diagnosis that carries a poor prognosis. This case report features a 68-year-old man, treated 4 years earlier with an endovascular aortic aneurysm repair, who presented with fever, low back discomfort, and abdominal pain. Given the concern for an infected endograft, the patient underwent explantation and replacement with a cadaveric aortoiliac cryograft. Ultimately, the pathology returned as an angiosarcoma. Although endovascular aortic aneurysm repair is the gold standard for abdominal aortic aneurysm repair in patients with suitable anatomy, there are trade-offs associated with less invasive approaches compared with open approaches.

Clinical characteristics associated with primary cardiac angiosarcoma outcomes: a surveillance, epidemiology and end result analysis

BACKGROUND

Primary cardiac angiosarcoma (PCAS) is a rare type of tumour. Furthermore, descriptions of the demographic features and prognostic factors of PCAS patients have been poorly reported.

METHODS

A population cohort study was conducted using retrospectively extracted data from the SEER (Surveillance, Epidemiology and End Results) database for patients with histological diagnoses of PCAS; the extracted information included demographic, treatment and outcome data.

RESULTS

A total of 168 cases of PCAS from 1973 to 2013 were included. The mean age at diagnosis was 44.4 ± 15.5 years. PCAS was more prevalent in men than in women. The majority of PCAS patients were white (67.3%), while the incidence of PCAS in black individuals was relatively infrequent (19.0%). In addition, 87 cases were classified as distant stage, 44 as regional stage, and 33 as localized stage. The median disease-specific survival (DSS) was 7.22 months, and the 1-, 2- and 5-year DSS rate for PCAS patients was 34.7%, 14.3% and 10.2%, respectively. Further multivariate analyses showed that an age at (greater than or equal to) 45 years (HR 2.165), no radiotherapy (HR 1.629), tumour size > 5 cm (HR 3.182), and the summary stage was associated with worse PCAS-related survival. Cancer-directed surgery and radiotherapy significantly improved the DSS for patients with PCAS (P < 0.05). The C-index of the nomograms was 0.706 (95% CI 0.654-0.758), and the calibration curves showed good agreement between the nomogram prediction and actual observation.

CONCLUSION

PCAS is a rare cancer that is prone to have poor prognoses. To understand PCAS more thoroughly, more cases with adequate information are needed.